Proximal Patellar Tendon Repair: Internal Brace Technique with Unicortical Buttons and Suture Tape George Sanchez, B.S., Marcio B

Home , Patellar dislocation, Patellar tendon, Patellar tendon rupture, Soft tissue

Technical Note

Proximal Patellar Tendon Repair: Internal Brace Technique With Unicortical Buttons and Suture Tape George Sanchez, B.S., Marcio B. Ferrari, M.D., Anthony Sanchez, B.S., Gilbert Moatshe, M.D., Jorge Chahla, M.D., Nicholas DePhillipo, A.T.C., and Matthew T. Provencher, M.D.

Abstract: Patellar tendon ruptures may be considerably limiting, especially in younger and highly active patients. These injuries ultimately result in a complete inability to maintain extension of the knee, thereby placing strict impediment on physical activity. As a result, a durable repair construct via surgery is necessary to allow patients to return to their pre- injury activity level. Because of the inherent difﬁculty in maintaining patellar tendon position after repair, and to avoid failure of the tendon healing to the patella, we recommend using an internal brace construct. The construct uses bone tunnels in the patella and also cortical buttons on the tibia with suture tape whipstitched through the tendon. We feel that this provides an enhanced ﬁxation construct. The purpose of this Technical Note is to describe our preferred method for proximal patellar tendon repair via an internal brace construct with unicortical buttons and suture tape.

atellar tendon ruptures constitute the third most episode with the knee in flexion and a concomitant Pcommon injury to the extensor mechanism of the extensor mechanism contraction.9 knee occurring mostly in patients younger than Performing a successful repair of the patellar tendon 40 years.1 This entity can be very disabling in the young might be challenging because of the high mechanical and active population, resulting in an inability to loads and poor blood supply of this tissue.10 Given these actively maintain extension. Furthermore, if the tendon various factors that may lead to ultimate failure, the fails to heal properly (length or tension), the knee range optimal technique for patellar tendon repair remains of motion can be significantly altered.2 unclear. In case of repair via transosseous sutures, the Conditions such as previous patellar tendonitis and main mode of failure is gap formation at the repair site repetitive microtrauma have been associated with a due to repetitive loading or a single event.11 In a recent higher risk of patellar tendon rupture.3 Other predis- cadaveric study, patellar tendon repair with suture posing causes are systemic diseases such as rheumatoid anchors yielded significantly less gap formation during arthritis or lupus erythematosus,4-7 prior bone tendon cyclic loading and resisted significantly higher ultimate bone harvest,8 or previous repeated steroid injections failure loads compared with transosseous sutures.12 at the patellar tendon.9 Usually, the mechanism of The purpose of this Technical Note is to describe our rupture is a low-velocity, indirect, minor traumatic preferred method of proximal patellar tendon repair via an internal brace construct with unicortical buttons and suture tape.

From the Steadman Philippon Research Institute (G.S., M.B.F., G.M., J.C., Objective Diagnosis N.D., M.T.P.), Vail, Colorado; Jackson Memorial Hospital (A.S.), Miami, Typically, patellar tendon ruptures are unilateral and Florida; and The Steadman Clinic (M.T.P.), Vail, Colorado, U.S.A. seen in highly active patients younger than 40 years.13 fl The authors report the following potential con icts of interest or sources of In cases of these ruptures, the patient should note a funding: M.T.P. receives support from Arthrex, JRF Ortho, and SLACK; and fl has patent numbers (issued): 9226743, 20150164498, 20150150594, traumatic injury involving knee exion in combination 20110040339. with quadriceps contraction. However, to accurately Received October 10, 2016; accepted November 21, 2016. diagnose a patellar tendon rupture, a thorough assess- Address correspondence to Matthew T. Provencher, M.D., Steadman Phil- ment encompassing history, as well as physical exami- ippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO nation and imaging, is necessary.13,14 Given the 81657, U.S.A. E-mail: [email protected] fi Ó 2016 by the Arthroscopy Association of North America signi cant pain and swelling associated with these 2212-6287/16978/$36.00 injuries as well as the patient’s apprehension, it is http://dx.doi.org/10.1016/j.eats.2016.11.004 usually difficult to complete a thorough physical

Arthroscopy Techniques, Vol -,No- (Month), 2017: pp e1-e7 e1 e2 G. SANCHEZ ET AL.

Fig 3. To perform the patellar tendon repair in a right knee using an internal brace technique, the distal pole of the patella should be prepared using a combination of curette, rasp, and burr. A bleeding surface is created, which will improve the reattachment of the tendon to the patella. It should be noted that the repair site on the patella is at the anterior cortical margin and drill tunnels and bony preparation should be completed at this area.

Fig 1. Patellar tendon repair performed in a right knee. After examination.14,15 Furthermore, the patient will likely a well-padded thigh tourniquet is placed on the upper thigh of be unable to stand up. However, if an examination is the operative leg and the surgical leg is prepped and draped in possible, the knee joint will be visibly swollen with a sterile fashion, a midline incision centered on the patella is marked tenderness at the anterior aspect. The patient performed 4 cm above the patella and extended distally to the will also exhibit palpable infrapatellar tendinous tibial tubercle. This will allow for complete exposure of the patellar tendon and its edges. Of note, care must be taken to defects and an inability to complete straight leg avoid damage to the patellar tendon and to the medial and lateral retinaculum.

Fig 4. Tunnel preparation in the patella of a right knee. To reattach the patellar tendon to the distal pole of the patella, 3 tunnels are performed. A 2.5-mm drill is used to perform the Fig 2. Patellar tendon repair using an internal brace tech- first tunnel, which should be parallel to the longitudinal axis nique with unicortical buttons and suture tape in a right knee. of the patella at the midline. The tunnel should be located After the patellar tendon is exposed, the distal patella pole is directly centered at the transverse distance of the patella and cleared of all scar tissue using a combination of a curette, rasp, at the anterior cortical margin to avoid damage to the cartilage and burr to expose the bony surface. All previous hardware and potential fracture. The first tunnel will be used as refer- from prior surgery is removed at this point of the procedure ence for placement of the medial and lateral tunnels, which with care taken to avoid patellar fracture or over-resection. should be parallel to this first tunnel. PROXIMAL PATELLAR TENDON REPAIR e3

are crucial. We recommend having a C-arm in the operative suite to evaluate patella position and avoid patella baja. After the induction of general anesthesia, the patient is placed in the supine position on the operating table (Video 1). A thorough physical examination is performed involving both knees to conﬁrm the diagnosis on the symptomatic side as well as to verify the patellar height on the normal side. A high thigh tourniquet is subsequently placed around the proximal aspect of the operative leg to establish a bloodless ﬁeld.

Surgical Approach A midline incision centered on the patella is performed 4 cm above the patella, extending distally to the tibial tubercle (Fig 1). A sharp dissection is then performed into the subcutaneous tissue and sharply through the retinaculum. After this, the prepatellar bursa is excised for access to the tendon and bone. The medial and lateral sides of the tendon must be visual- ized to ensure the optimal position of the suture tape. In chronic cases, there is usually scar tissue in the injury zone between the patellar tendon and the distal pole of the patella. In acute cases, there is usually a significant Fig 5. After the distal pole of the right patella is cleared of all amount of hematoma, as well as scar tissue and scar tissue and a bleeding surface is achieved, 3 high-strength FiberTape sutures (Arthrex, Naples, FL) are used to whipstitch the tendon, first medially and laterally while leaving the ends out distally for fixation and augmentation, and then, the last suture is placed in the midline of the tendon. (PT, patellar tendon.) raises.14,15 Given the high degree of swelling and apprehension, acute ruptures of this tendon are initially misdiagnosed in a considerable percentage of cases, reported as high as 38%.14 Therefore, to minimize this possibility, imaging should be undertaken. For confirmation of a patellar tendon rupture, ante- roposterior and lateral radiographs of the knee in a supine position should be taken. In particular, lateral radiographs should be performed through the use of a horizontal beam while the knee is in flexion, if tolerated. To quantify the extent of the injury, the Insall- Salvati ratio should be employed, in which the length of the patellar tendon is divided by the length of the patella. A ratio of 1 is considered “normal,” whereas a ratio of <0.8 is categorized as patella baja and >1.2 as patella alta.16,17 Fazal et al.18 showed that all patients with a patellar tendon rupture exhibited an Insall- Salvati ratio greater than 1.2, whereas all patients in the control group were between 0.8 and 1.2. Fig 6. Once the tunnels are complete and the right patellar tendon is whipstitched, the sutures located at the proximal Surgical Technique end of the tendon are passed through the tunnels with suture passers. Ultimately, the middle tunnel should contain 2 suture Preoperative Setup ends. Of note, it is important to ensure that all the bone spikes When performing this technique, detailed planning, are removed from the tunnel entrance to avoid damage to the preparation of the operative suite, and surgical setup sutures during knee range of motion. e4 G. SANCHEZ ET AL.

posterior to the distal patella cortex and exit just deep to the quadriceps tendon superiorly. A suture passer is placed in the tunnels to facilitate suture passage later on in the technique. Once these tunnels are ﬁnalized, the suture passers are left in place. To minimize the risk of fractures and convergence of the tunnels, it is important to maintain a sufﬁcient bony bridge between the tunnels. A small longitudinal slit in the quadriceps tendon is then performed to make it easier to retrieve the sutures, and then this will be the window in which the sutures are tied at the superior pole of the patella.

Suture Passage and Securement Using 3 high-strength FiberTape sutures (Arthrex, Naples, FL), the tendon is whipstitched. Starting with a FiberTape suture medially and one laterally, the tendon is whipstitched on each end, leaving out the distal ends of the FiberTape for ﬁxation and augmentation via the internal brace technique (Fig 5). After this, one high- strength FiberTape suture (Arthrex) is used to whipstitch the central portion of the patellar tendon.

Fig 7. Final view of a right patellar tendon repair through the Distal Fixation at the Tibia internal brace technique with unicortical buttons and suture A 3.7-mm spade tip drill (Arthrex) is used to make 2 tape. After the suture ends are tied to one another at the drill tunnels for 2 pectoralis major button insertions proximal pole of the patella, the knee should be guided through a range of motion examination to evaluate the repair (Arthrex) at the most proximal insertion of the tibial integrity and rule out any possible overtensioning. Moreover, tubercle on the medial and lateral edges right at the exit the patellar height must be evaluated at this point to confirm of the FiberTape whipstitch. FiberTape suture (Arthrex) optimal positioning of the patella. (TT, tibial tubercle.) ends from the medial and lateral sides are passed through 2 pectoralis major buttons (Arthrex). A small right angle is used to clear space under the cortex to retinacular rupture, both medially and laterally. This is allow for button flipping. The pectoralis major buttons evacuated with suction and bulb irrigation. are inserted and flipped on each side of the tibial tubercle with one limb of the FiberTape suture from the Preparation of Patella Bone Bed and Tendon respective side inserted. A tension-slide technique is With traction on the patellar tendon, all adhesions then used to tension the FiberTape through the button, and scarring are removed to allow for full mobilization. and then tie the suture limbs. The use of these pector- The proximal ruptured end of the patellar tendon is alis major buttons (Arthrex) allows for durable distal cleared of all scar tissue with a sharp 15-blade. It is fixation of the patellar tendon at the tibia. Once a important to expose normal tendon tissue to facilitate secure fixation has been reached, the knots are buried healing. However, this should be performed with in the soft tissue with a free needle after the knots are caution given that excessive removal may lead to pa- fully secured. tella baja. The distal patella pole is cleared of all soft With the ends of all FiberTape sutures located at the tissue as well as scar tissue with a rongeur for full proximal end of the tendon, the 2 limbs of the central exposure of the bony surface. This bony surface is then suture are then passed through the central tunnel prepared with a combination of a curette, rasp, and burr (Fig 6), whereas one limb is brought medially and the (Fig 2). It should be noted that the repair site on the other laterally through the tunnels. Therefore, there are patella is at the anterior cortical margin; therefore bony 4 suture ends from the patellar tendon passed through preparation and drill tunnels should be performed at 3 tunnels in the patella. The sutures are passed through this site (Fig 3). the tunnels with suture passers. Each suture can then Once the bony surface has been prepared, the bone be tied to another suture from another tunnel through tunnels are drilled in the patella in a distal-proximal 6-squared surgical knots, thereby forming a tight repair direction. A drill guide for a 2.5-mm drill is used to construct (Fig 7). The patella is maintained in an protect the soft tissue and 3 tunnelsdcentral, medial, anatomic position, whereas the knots are tied through and lateraldare drilled parallel to the longitudinal axis the quadriceps slit, and a knot pusher may be used to of the patella (Fig 4). The drill tunnels should begin just facilitate secure knot tying. PROXIMAL PATELLAR TENDON REPAIR e5

Table 1. Pearls and Pitfalls the patella is sutured to the capsule. After this, sub- Pearls Pitfalls cutaneous sutures are placed and the skin is closed. The pearls and pitfalls as well as the advantages and dis- Perform a complete Failure to identify any possible preoperative examination concomitant injuries advantages of this technique are reviewed in Tables 1 with the patient under and 2, respectively. anesthesia to evaluate the extent of patellar instability Meticulous bony preparation Failure of substantial Postoperative Rehabilitation with the aid of shavers and debridement at the distal After surgery, the patient uses a knee immobilizer and curettes is advocated to patella may impair healing maintains noneweight-bearing status for 6 weeks. enhance healing potential of potential the repair Formal rehabilitation begins immediately post- Remove any scar tissue at the Improper removal of scar tissue operatively and focuses on restoration of patellofemoral proximal end of the tendon to at the proximal end of the range of motion, quadriceps activation, edema control, enhance healing potential tendon may impair healing and pain management. Passive range of motion is fi Enough spacing between the Insuf cient spacing between initiated on the first day postoperatively and is gradu- bone tunnels must be tunnels may result in fracture performed to reduce risk of and/or convergence ally progressed to full range of motion as tolerated, with fracture and/or convergence the goal of attaining at least 90 of knee flexion by A suture passer should be used Oversecurement of the patella 2 weeks postoperatively. During the first 6 weeks, the to facilitate suture passage as well as excessive patient’s primary exercises are patella and patellar through the tunnels debridement of the patellar tendon mobilizations, active and passive knee range of tendon may lead to patella baja motion, and quadriceps activation exercises. At Use locking sutures that can Failure to identify both sides of 6 weeks, patients are permitted to gradually wean off hold in the patella tendon the tendon along with any crutches and begin spinning on a stationary bike with tissue. Identification of both tendon degeneration may no resistance. The patient is cleared to be off crutches sides of the patellar tendon result in procedure failure once he or she can fully ambulate without a limp and leads to optimal positioning Once the repair is complete, Bone spikes at the tunnel show adequate muscular control of his or her verify knee range of motion entrance may compromise quadriceps. to guide postoperative the suture during flexion Once they are full weight bearing, patients begin rehabilitation exercises and lead to closed chain strengthening exercises with training procedure failure periodization focused on developing muscular endur- Consider taking a radiograph to fi ensure that the patella is not ance rst, followed by strength and power. Strength- fixed in patella baja with the ening exercises with weight-bearing status begin at other limb as a reference for 8 weeks postoperatively, with limited leg press to 70 of patellar position knee flexion allowed at 10 weeks. Patients may begin running exercises at 6 months with initiation of speed Repair Verification and Closure and agility drills at this time. A gradual return to play If the repair exhibits overtensioning or any difficulty progression is initiated at 7 months postoperatively involving tendon approximation up to the patella, the knee may be extended for tension relief off of the Table 2. Advantages and Disadvantages repair. To ensure the proper location of the patella after Advantages Disadvantages repair, the knee should be guided through a range of Evaluation of the patellar This technique is not motion examination to evaluate the repair integrity and cartilaginous surface and recommended for unviable rule out any possible overtensioning. The surgeon must patellar tendon integrity tendons be aware that additional surgery may be required if the The patellar height can be Tunnels in the patella increase patella is not in the desirable position with the knee in measured and changed before the risk of patellar fracture slight flexion. Lastly, verification is needed to assure the final fixation and may compromise bone integrity that the patella is not fixed in a patella baja position. For fl The internal brace concept Cannot be used for distal this step, uoroscopy may be used with the contralat- provides complementary ruptures of the patellar eral limb and Blumensaat’s line serving as reference strength to the fixation of the tendon (however, these are points. Knee range of motion should be assessed to patellar tendon not common) determine the safe range of motion during physical Allows for maintenance of Locking sutures can worsen the reduction while the tendon patellar tendon integrity therapy as well as to ensure that the knee is not stiff. heals and spreads out tension There should be no pull-off of the tendon through a Greater cost associated with near full range of motion. pectoralis button Finally, the tourniquet is released and hemostasis is reconstruction than the re-established. Thorough irrigation is performed and standard technique e6 G. SANCHEZ ET AL. after completion of a functional sports examination. In this Technical Note, we have described our Return to sports or activity is allowed when normal preferred method for patellar tendon repair via an strength, stability, and knee range of motion compa- internal brace construct with unicortical buttons and rable with the contralateral side have been achieved suture tape. On the basis of previous findings,32 we (usually 6-9 months postoperatively). hypothesize that the pectoralis button fixation in comparison with other techniques allows for a substantial improvement in the strength of the repair construct for Discussion the patellar tendon, which has significant forces across Patellar tendon ruptures are rare injuries with an it. Furthermore, it helps spread out the tension, thereby incidence rate of 6.8 of 1,000,000 per year, with 78% of also distributing tension on the posterior aspect of the all injuries occurring in male patients at a mean age of anterior tibial cortex. Lastly, this fixation method also 49 years.19 Such ruptures require immediate repair to allows for avoidance of possible protrusion of knots, re-establish knee extensor continuity and allow early which may be encountered in suture anchor repair motion due to evidence showing a prolonged time in- techniques. Randomized controlled clinical trials terval between trauma and surgery to be a major factor comparing the internal brace construct with unicortical for positive treatment outcome.14,15,20-22 Although they button and suture tape with other techniques widely exhibit a peak incidence in the seventh to eighth used for patellar tendon repair are needed to fully assess decades of life with a sharp decline thereafter,19 the efficacy of our described technique. patellar ruptures occur in younger patients typically as a result of low velocity, indirect, minor traumatic References episode with the knee in flexion with a concomitant 1. Khurana A. Samseier LE, et al. Quadriceps and patellar 9 extensor contraction. This pathology is particularly tendon rupture [Injury 2006;37(6):516-19]. Injury disabling in the young and active population, resulting 2007;38:1327-1328. in an inability to actively maintain extension. This re- 2. Scott WN, Insall JN. Insall & Scott surgery of the knee. sults in a significant alteration in knee range of motion.2 Philadelphia: Elsevier/Churchill Livingstone, 2012. In the older population, multiple factors contribute to 3. Kelly DW, Carter VS, Jobe FW, Kerlan RK. Patellar and d ’ degenerative changes that ultimately result in quadriceps tendon ruptures jumper s knee. Am J Sports rupture.4-9,23,24 Med 1984;12:375-380. 4. Peiró A, Ferrandis R, Garcia L, Alcazar E. Simultaneous High mechanical loads and poor tissue blood supply at 10 and spontaneous bilateral rupture of the patellar tendon the patellar lead to a particularly challenging repair. A in rheumatoid arthritis. A case report. Acta Orthop Scand balance must be struck between the repair strength and 1975;46:700-703. increased strand number and suture caliber, both of 5. Potasman I, Bassan HM. Multiple tendon rupture in 25 which increase the risk of wound complications. systemic lupus erythematosus: Case report and review of Exact causes and optimal repair techniques for each the literature. Ann Rheum Dis 1984;43:347-349. tendon rupture subtype remain largely unclear. A 6. Wener JA, Schein AJ. Simultaneous bilateral rupture of cadaveric biomechanical study in the context of the patellar tendon and quadriceps expansions in systemic hamstring tendon rupture repair, which tested 3 suture lupus erythematosus. A case report. J Bone Joint Surg Am materials and techniques, concluded that the Fiberwire- 1974;56:823-824. Baseball combination was most durable, whereas the 7. Sullivan RL. Traumatic bilateral patellar tendon rupture with chronic renal disease. Wis Med J 1986;85:12-13. Fiberwire-Kessler combination showed the lowest 26 fi 8. Langan P, Fontanetta AP. Rupture of the patellar tendon elongation after cyclic loading. This study exempli es after use of its central third. Orthop Rev 1987;16:317-321. the need for further research in tendon rupture repair 9. Flanigan DC, Bloomfield M, Koh J. A biomechanical 11 efficacy. comparison of patellar tendon repair materials in a bovine An additional factor, aside from suture material and model. Orthopedics 2011;34:e344-e348. technique, is the repair attachment technique. Standard 10. Bibbo C, Milia MJ, Gehrmann RM, Patel DV, repair calls for transpatellar suture attachment via Anderson RB. Strength and knot security of braided osseous tunnels. Two separate biomechanical studies polyester and caprolactone/glycolide suture. Foot Ankle Int evaluated the standard transosseous sutures compared 2004;25:712-715. with suture anchors, which have been successfully 11. Ravalin RV, Mazzocca AD, Grady-Benson JC, Nissen CW, applied since their introduction by Goble27 in 1985.12,28 Adams DJ. Biomechanical comparison of patellar tendon repairs in a cadaver model: An evaluation of gap forma- Both studies concluded that suture anchors were tion at the repair site with cyclic loading. Am J Sports Med superior to transosseous sutures in terms of gap 12,28 2002;30:469-473. formation resistance and mean load to failure. 12. Ettinger M, Dratzidis A, Hurschler C, et al. Biomechanical Additional reported suture anchor advantages include properties of suture anchor repair compared with trans- reduced operation time, easily accessible implantation osseous sutures in patellar tendon ruptures: A cadaveric site, and earlier functional rehabilitation.29-31 study. Am J Sports Med 2013;41:2540-2544. PROXIMAL PATELLAR TENDON REPAIR e7

13. Panni AS, Vasso M, Cerciello S. Acute patellar dislocation. 23. Herbort M, Raschke MJ. [Ligament ruptures of the lower What to do? Knee Surg Sports Traumatol Arthrosc 2013;21: extremity in the elderly]. Unfallchirurg 2011;114:671-680 275-278. [in German]. 14. Siwek CW, Rao JP. Ruptures of the extensor mecha- 24. Lobenhoffer P, Thermann H. [Quadriceps and patellar nism of the knee joint. J Bone Joint Surg Am 1981;63: tendon ruptures]. Orthopade 2000;29:228-234 [in German]. 932-937. 25. Benthien RA, Aronow MS, Doran-Diaz V, Sullivan RJ, 15. Bhargava SP, Hynes MC, Dowell JK. Traumatic patella Naujoks R, Adams DJ. Cyclic loading of Achilles tendon tendon rupture: Early mobilisation following surgical repairs: A comparison of polyester and polyblend suture. repair. Injury 2004;35:76-79. Foot Ankle Int 2006;27:512-518. 16. Grelsamer RP, Meadows S. The modiﬁed Insall-Salvati 26. Petri M, Ettinger M, Dratzidis A, et al. Comparison of three ratio for assessment of patellar height. Clin Orthop suture techniques and three suture materials on gap for- 1992;(282):170-176. mation and failure load in ruptured tendons: A human 17. Kadakia NR, Ilahi OA. Interobserver variability of the cadaveric study. Arch Orthop Trauma Surg 2012;132:649-654. Insall-Salvati ratio. Orthopedics 2003;26:321-323. discus- 27. Goble EM, Somers WK, Clark R, Olsen RE. The devel- sion 323-4. opment of suture anchors for use in soft tissue ﬁxation to 18. Fazal MA, Moonot P, Haddad F. Radiographic features bone. Am J Sports Med 1994;22:236-239. of acute patellar tendon rupture. Orthop Surg 2015;7: 28. Bushnell BD, Byram IR, Weinhold PS, Creighton RA. The 338-342. use of suture anchors in repair of the ruptured patellar 19. Clayton RAE, Court-Brown CM. The epidemiology of tendon: A biomechanical study. Am J Sports Med 2006;34: musculoskeletal tendinous and ligamentous injuries. 1492-1499. Injury 2008;39:1338-1344. 29. Gaines RJ, Grabill SE, DeMaio M, Carr D. Patellar tendon 20. Meissner A, Tiedtke R. [Tendon rupture of the extensor repair with suture anchors using a combined suture muscles of the knee]. Aktuelle Traumatol 1985;15:170-174 technique of a Krackow-Bunnell weave. J Orthop Trauma [in German]. 2009;23:68-71. 21. Levy M, Goldstein J, Rosner M. A method of repair for 30. Maniscalco P, Bertone C, Rivera F, Bocchi L. A new quadriceps tendon or patellar ligament (tendon) ruptures method of repair for quadriceps tendon ruptures. A case without cast immobilization. Preliminary report. Clin report. Panminerva Med 2000;42:223-225. Orthop 1987;(218):297-301. 31. Richards DP, Barber FA. Repair of quadriceps tendon rup- 22. Roudet A, Boudissa M, Chaussard C, Rubens-Duval B, tures using suture anchors. Arthroscopy 2002;18:556-559. Saragaglia D. Acute traumatic patellar tendon rupture: 32. Rabuck SJ, Lynch JL, Guo X, et al. Biomechanical com- Early and late results of surgical treatment of 38 cases. parison of 3 methods to repair pectoralis major ruptures. Orthop Traumatol Surg Res 2015;101:307-311. Am J Sports Med 2012;40:1635-1640.